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Running head: DAILY CHLORHEXIDINE BATHING EFFECTS ON HOSPITAL

Daily Chlorhexidine Bathing Effects on Hospital Acquired Infection Rates


Alexandra Bair
University of South Florida

DAILY CHLORHEXIDINE BATHING EFFECTS ON HOSPITAL

Abstract
Clinical problem: Patients in intensive care units (ICUs) are at a higher risk for developing
hospital acquired infections (HAIs).
Objective: To determine whether chlorhexidine gluconate (CHG) bathing will reduce the
incidence rates of HAIs in ICUs. PubMed and CINAHL were used in combination to search for
randomized controlled trials (RCTs) about different bathing techniques and the effects on
reducing HAIs with ICU patients. Guidelines and recommended practices were obtained from
the Centers for Disease Control and Prevention (CDC) website in preventing catheter related
infections. Key words used in searching for literature on the subject include chlorhexidine
gluconate bathing, intensive care units, critical care, hospital acquired infections, and prevention.
Results: The clinical guidelines and recommended practices from the CDC state that daily
cleansing of the patient with 2% CHG wipes will reduce catheter-related blood stream infections
(CDC, 2011). This recommendation and practice is supported by three RCTs within the clinical
setting. Results showed CHG wipes reduced the incidence of HAIs in patients within ICUs
compared to other standard measures of care.
Conclusion: Critical care patients who have daily bathes with CHG wipes have a decreased
incidence of HAIs. There will be a potential decrease in the patients length of stay in the
hospital and hospital costs.

DAILY CHLORHEXIDINE BATHING EFFECTS ON HOSPITAL

Daily Chlorhexidine Bathing Effects on Hospital Acquired Infection Rates


Hospital acquired infections (HAIs) are problematic to both the patient and the hospital.
Causing more treatment, these infections increase the patients length of stay in the hospital and
increase costs to the hospital (CDC, 2011). About 30% of patients in intensive care units (ICUs)
are affected by HAIs (Cassir et al., 2015). It is estimated that 80,000 catheter-related bloodstream infections occur in ICUs each year (CDC, 2011). This is only one example of the many
types of HAIs.
Preventing HAIs is the best way to solve these problems for the patient and the hospital.
Infections are frequently caused by colonization of organisms on the surface of the skin invading
through a break or tear in the skin integrity or along a central venous catheter (Cassir et al.,
2015). Daily cleansing of the skin through antiseptic solution has the potential to decrease the
risk of infection (Mimoz et al., 2015). Many hospitals use different standard measures of care to
clean their patients. Other standard measures of care utilized in the studies were soap and water
bathing, povidone iodine solution, and a topical polymyxin and tobramycin combination. CHG
is a broad-spectrum bactericidal antiseptic solution (Cassir et al., 2015). The guidelines provided
by the CDC (2011) for prevention of intravascular catheter-related infections recommended
washing patients with CHG daily (CDC, 2011). Including the recommended practice of using
CHG wipes to cleanse all ICU patients has the possibility to prevent more HAIs than just
catheter-related infections.
By decreasing HAIs, there is potential for overall improvement in patient outcomes.
This strive for improvement should be multidisciplinary with physicians, nursing staff, infection
control personnel, and anyone else involved in the patient care (CDC, 2011). The aim is to
evaluate the effectiveness of CHG bathes on ICU patients as a method to reduce the incidence of

DAILY CHLORHEXIDINE BATHING EFFECTS ON HOSPITAL

HAIs. In ICU patients, how does daily CHG bathing compare to other standard measures of
care, effect the rate of hospital acquired infections for a three-month period? Expected outcome
measures include the incidence rate of HAIs in ICU patients in a three-month period.
Literature Search
PubMed and the Cumulative Index to Nursing and Allied Health Literature (CINAHL)
databases were used to search for randomized, controlled trials (RCTs) involving CHG bathing
in ICUs. Guidelines from the CDC were used about recommended practices to prevent
intravascular catheter-related infections. Key words used in searching for literature on the
subject include chlorhexidine gluconate bathing, intensive care units, critical care, hospital
acquired infections, and prevention. A filter for searching the publication date of the literature
was placed from 2011 to 2016 to include the most recent research.
Literature Review
From the literature search, three RCTs investigating the use of CHG bathing for critical
care patients were evaluated. One clinical guideline from the CDC was also examined for
recommendations of practice regarding CHG bathing and reduction of HAIs. Camus et al.
(2014) created a placebo-controlled, randomized, double-blind study. The study involved
intubated patients in ICUs of three French university hospitals. Patients randomly received a
polymyxin and tobramycin (P/T) regimen, a nasal mupirocin with chlorhexidine body wash
(M/C) regimen, or a placebo. The time period of the study was for the period of intubation and
24 hours after intubation. The assessed incidence rates were per 1,000 study days of methicillinresistant Staphylococcus aureus (MRSA) HAIs. There were 515 patients analyzed in the three
groups. The results of the M/C regimen compared to the placebo showed a statistically
significant decrease in the incidence rate of MRSA infection with 21 incidences of MRSA

DAILY CHLORHEXIDINE BATHING EFFECTS ON HOSPITAL

without M/C and 8 incidences of MRSA with M/C. The results of the P/T regimen compared to
the placebo showed an increase in the incidence rate with there being 22 infections of MRSA
with P/T regimen versus the 7 incidences without P/T. This study concluded that the use of M/C
combination in intubated patients in ICUs reduced the incidence of HAIs related to MRSA
(p=.04). The strengths of this study consisted of patients randomly assigned to groups and each
group was similar in regards to baseline variables. Also, this study was a double-blind study.
The weaknesses of this trial included a nurse distributing the nasal ointment treatment and the
absence of molecular typing of MRSA isolates.
Cassir et al. (2015) studied the effect of HAIs on patients in intensive care units by
cleansing techniques. The design of the study was a randomized control trial in a 14-bed ICU in
France. A total of 325 ICU patients were registered for the study. The intervention group was
required to have daily CHG bathing with one-time use, throwaway cloths soaked with 2% CHG,
while the control group was cleansed with soap and water. The study was done over 6 months.
The study resulted in the intervention group with CHG cleansing showed a significant decrease
in incidence of HAIs (29 vs 56; p = .01). This study demonstrated a noteworthy reduction in the
rate of overall HAIs when the patients were bathed with CHG cleansing. Some strengths of this
study were that they reported a possible case of sepsis within lab samples performed and patients
were randomly assigned to groups. All patients were similar in regards to baseline variables.
Limitations of the study included a small population size from a single ICU and the nurses had
knowledge of the intervention and control groups.
Mimoz et al. (2015) designed a study to determine if CHG bathing had more success than
povidone iodine (PI) in preventing HAIs. The design of the study was an open-label,
multicenter, randomized, controlled, two-by-two factorial study. The patients were from 11

DAILY CHLORHEXIDINE BATHING EFFECTS ON HOSPITAL

different ICUs in France. Inclusion criteria included that the patients had to require at least one
central venous catheter for two days or greater. Randomization was through a web-based
system. Skin preparation procedures were the basis for the four groups in the clinical trial. CHG
was one, PI was the second, scrubbing the skin prior to application was the third, and application
with no scrubbing was the fourth group. The staff who performed the testing of the catheters and
blood samples were all masked to the treatment group assignments. The study had 2,349 patients
participate in the study. The appearance of infection in the CHG group was 28 per 1,000
catheter-days compared to 77 per 1,000 catheter-days for the PI group. The CHG group had a
significant decrease in catheter-related infections (CRIs) (p = .003). The study verified the use of
2% CHG for cleansing the skin of patients in an ICU was associated with a significant decrease
in the incidences of CRIs and colonization. The strength of the study is this is the largest study
of its kind. Some of the weaknesses include the patients and staff were aware of the group
assignments and formal audits were not done to regularly assess the adhesion to the study
protocol.
The CDC guidelines (2011) for prevention of intravascular CRIs evaluates RCTs to
promote evidence-based recommended practices. In the guidelines, one of the recommended
practices is using a solution of 2% CHG wash daily to clean the skin and reduce colonization of
organisms and catheter-related blood-stream infections (CRBSIs). Evidence shows that daily use
of CHG wipes to bath patients decreases the rate of CRBSIs.
Synthesis
Camus et al. (2014) established that M/C interventions, which is a combination of nasal
mupirocin and chlorhexidine body wash used on intubated ICU patients greatly reduced the
incidence of HAIs (p=.04). Cassir et al. (2015) conducted a study that yielded similar results

DAILY CHLORHEXIDINE BATHING EFFECTS ON HOSPITAL

with daily CHG bathing significantly decreasing the overall HAI incidence (p=.01). Mimoz et
al. (2015) demonstrated in their study that CHG was more effective than povidone iodine for
skin antisepsis and had a six-fold decrease in incidences of HAIs (p=.0002). Lastly, the CDC
guidelines (2011) advocate the use of CHG in daily cleansing of patients to reduces the incidence
of HAIs. Camus et al. (2014) and Cassir et al. (2015) both looked at HAIs in general. The CDC
guidelines (2011) and Mimoz et al. (2015) looked specifically at catheter related HAIs.
These studies all support the effectiveness of daily CHG bathes for reducing the overall
incidence rates of HAIs compared to other standard of care practices in the critical care
population. Differences among these RCTs include sample size, the standard care of practice
used to compare against CHG bathing, and how the studies adhered to the protocols and
maintained the blind studies. It is known that CHG works to reduce colonization of organisms
on the skin and decrease the overall incidence rate of CRBSI (CDC, 2011). By inductive
reasoning and the RCT literature, the use of CHG decreases the overall incidence rate of HAIs.
These findings can significantly impact the clinical practice by reducing the overall incidence of
HAIs in ICU patients. By utilizing daily CHG bathing in critical care areas, new practices and
nursing knowledge is increased and overall patient outcomes are improved. Additional research
is necessary to determine how effective CHG bathing is on neonates, children, and noncritical
hospital patients.
Clinical Recommendations
CDC guidelines recommend using daily CHG bathing to reduce CRBSIs in patients with
intravascular catheters. CHG bathing can be used in all ICU patients to reduce the incidence of
HAIs. Critical care areas and ICUs could significantly benefit from the use of CHG baths since
there are more potential risks for infections like indwelling catheters and lines. ICUs and other

DAILY CHLORHEXIDINE BATHING EFFECTS ON HOSPITAL

critical care areas should begin using CHG baths daily instead of other standards of care in order
to greatly reduce infection rates. In combination with good hand hygiene and recommended
protocols for removal of indwelling catheters, CHG bathing in ICUs can reduce HAI incidences.
More research is warranted to determine if reducing HAIs will also reduce the patients length of
stay, hospital costs, and overall patient outcomes.

DAILY CHLORHEXIDINE BATHING EFFECTS ON HOSPITAL

References
Camus, C., Sebille, V., Legras, A., Garo, B., Renault, A., Le Corre, P., ... Bellissant, E. (2014,
January 25). Mupirocin/chlorhexidine to prevent methicillin-resistant staphylcoccus
aureus infections: post hoc analysis of a placebo-controlled, randomized trial using
mupirocin/chlorhexidine and polymyxin/tobramycin for the prevention of acquired
infections in intubated patients. Infection, 42, 493-502. http://dx.doi.org/10.1007/s15010013-0581-1
Cassir, N., Thomas, G., Hraiech, S., Brunet, J., Fournier, P. E., La Scola, B., & Papazian, L.
(2015). Chlorhexidine daily bathing: impact on health care-associated infections caused
by gram-negative bacteria. American Journal of Infection Control, 43, 640-643.
http://dx.doi.org/10.1016/j.ajic.2015.02.010
Centers for Disease Control and Prevention [CDC]. (2011). Guidelines for prevention of
intravascular catheter-related infections. 1-83. Retrieved from
https://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf
Mimoz, O., Lucet, J. C., Kerforne, T., Pascal, J., Souweine, B., Goudet, V., ... Timsit, J. F. (2015,
November 21). Skin antisepsis with chlorhexidine-alcohol versus povidone iodinealcohol, with and without skin scrubbing, for prevention of intravascular-catheter-related
infection (CLEAN): an open-label, multicentre, randomised, controlled, two-by-two
factorial trial. The Lancet, 386, 2069-2077. http://dx.doi.org/10.1016/S01406736(15)00244-5